Failure to Document Meal Assistance for Dependent Residents on Specialized Diets
Penalty
Summary
The facility failed to ensure that two dependent residents received and had documented assistance with meals three times a day as ordered. Resident 2 was admitted with conditions including a left tibia medial malleolus fracture, GERD, dementia, and muscle weakness, and had an MDS showing moderately impaired cognition and dependence on staff for all ADLs. Orders in effect included a fortified mechanical soft diet with thin liquids and a Restorative Nursing Assistant feeding program. Review of Resident 2’s Documentation Survey Reports for February and March 2026 showed missing documentation that the resident was assisted with meals three times daily on multiple specified dates, despite the resident’s dependence on staff and specialized diet and feeding program orders. Resident 8 was admitted with COPD, kidney transplant status, dementia, anemia, and morbid obesity, with an MDS indicating severely impaired cognition and dependence on staff for all ADLs. Active orders included a fortified pureed diet with mildly thick consistency. Review of Resident 8’s Documentation Survey Reports for February and March 2026 similarly showed no documented evidence that the resident was assisted with meals three times a day on multiple specified dates. During interviews and concurrent record reviews, the RN Supervisor confirmed the lack of documentation for both residents on the identified dates and acknowledged the need to ensure meals were recorded and that residents eat at least three times a day. The facility’s Food and Nutrition Services policy stated that each resident is to be provided with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.